一名 55 歲高血壓病史個案自述嚴重頭痛及視力模糊，測量血壓為 220/130 mmHg。護理師應優先採取何種行動？
A 55-year-old client with a history of hypertension reports severe headache and blurred vision. The blood pressure is 220/130 mmHg. What is the nurse's priority action?
- APlace the client in a semi-Fowler's position將病人置於半坐臥位
- BPerform a comprehensive neurological assessment進行全面的神經學評估
- CNotify the healthcare provider immediately✓ 正解立即通知醫療提供者
- DAdminister the prescribed PRN antihypertensive medication給予處方上的按需降血壓藥物
此個案呈現高血壓急症 (Hypertensive Emergency)，其特徵為血壓 >180/120 mmHg 並伴隨標的器官損傷症狀（頭痛、視力模糊）。此情況具有生命威脅，需立即通知醫師以啟動緊急降壓與監測計畫。D 選項雖會執行，但需在醫師指導下進行；A 與 B 是後續評估與護理措施，非最首要的緊急通報。
This client presents with hypertensive emergency (BP >180/120 mmHg with end-organ symptoms such as severe headache and blurred vision). This is life-threatening and requires immediate notification of the provider to initiate emergency antihypertensive therapy and monitoring. PRN medication and positioning are supportive but should occur in conjunction with provider notification, not in place of it.
美國醫院有明確的 Hypertensive Emergency 處置 protocol，護理師可預先準備緊急用藥；台灣則嚴格執行醫師醫囑。